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The $64,000 question

When I posted last month about all the topics that I was planning forthcoming posts on, the one that the overwhelming majority of readers (well, three) wanted to know more about was why shell shock is not ‘what we now know as PTSD’. In fact, one reader was so keen to know more that she emailed me, asking me for a one-line summary to discuss with a student. After some thought, I replied that the soundbite answer is that PTSD is a medical diagnosis, while shell shock is a cultural idea.

It is, of course, more complicated than this, although being forced to summarize my rather disparate ideas on the subject was a useful discipline and I hope that my reader and her student found enough meat on those rather bare bones to chew over in the interim. But it is just a sound bite, so the question remains, why don’t I think that PTSD and shell shock are different terms for the same thing?

I will start with PTSD, the condition that I know rather less about but which I understand primarily as a medical diagnosis. It has been part of public consciousness since 1980, when it was first officially recognised and appeared in DSM III, the Diagnostic and Statistical Manual. DSM V has recently been published, including a revised, hotly contested definition of PTSD which complicates the ‘constellation of symptoms’ that are classified as defining the condition. Indeed, PTSD has never not been contested. As Ben Shephard has pointed out, the recognition of the condition was viewed by some from the outset as politically driven, to improve state benefits for Vietnam veterans. He also notes, however, that the recognition of PTSD in DSM III gave a previously ‘vague and emotive “post-Vietnam syndrome” … real intellectual authority.’ [1] This is an authority that the term has, despite much argument, maintained for over thirty years. It is not only ‘the overriding diagnosis for the psychiatric disorders of war’, [2] it is also a legally and medically recognized response to civilian traumas, diagnosed in victims of crime, industrial accident and medical traumas.

So how does this differ from shell shock? Shell shock was, after all, a term coined by a doctor attempting to diagnose a constellation of inexplicable symptoms which are now recognized as those associated with psychological wounding. The problem is that, as a medical concept, ‘shell shock’ was originally used in relation to the theory that shell blast (and burial alive caused by shell fire) resulted in microscopic neurological damage which in turn caused the more visible and seemingly inexplicable symptoms on display. Although an idea that continued to have its supporters throughout the First World War, it was one which did not stand up to scrutiny and, by mid-1916, shell shock was generally discredited as a medical term. Indeed, Charles Myers, credited with coining the term, would later write that it was ‘a singularly ill-chosen term; and in other respects … has proved a singularly harmful one’, [3] distracting, as it seemed to Myers, from a proper understanding of the psychic damage men were suffering from in response to the traumas of danger, pain and, above all, fear. At the same time, the British military authorities, concerned that the vibrant phrase was encouraging an epidemic of incurable nervous responses and convinced that the weakness it appeared to expose was contagious, with one shell-shocked soldier within a unit causing others to suffer, or pretend to suffer, from the condition as well, forbad its use in favour of more bureaucratic terms such as ‘Not Yet Diagnosed (Nervous).’

Yet the phrase did not disappear. Almost as soon as it was coined it took on a life of its own, moving, as Jay Winter has argued, ‘from the medical to the metaphysical’ and turning ‘from a diagnosis into a metaphor.’ [4] From soldiers who, on seeing their comrades suffering from psychological wounds commented, ‘there was such a thing as shell shock’ to contemporary usage where to be shell-shocked by something is the common rhetorical response to almost any unexpected event, the term has become deeply embedded in the English language. Beyond this, shell shock has, for many years, been the symbolic wound of the war, the condition which all men suffered from and which was the clearest expression not only of their suffering and silencing (hysterical mutism was one symptom of the condition), but of the madness of war itself. It is not for nothing that the image of Blackadder with underpants on his head and pencils up his nose, feigning insanity as the only way out of an insane situation, is one of the two most iconic of the final episode of Blackadder Goes Forth. (The other, of course, is the final fade from men charging over the top to a poppy field, with death being the only other exit from the insanity of warfare.) Shell shock, then, has come to represent the psychological damage that war inflicts on men in a way that was not only not intended originally but also in ways that go far beyond any medical understanding of the psychological trauma of war.

Yet it is not simply that shell shock is, in one way, far more wide-ranging as a term than PTSD. Because in another way it is a far narrower term. PTSD did not merely refashion pre-existing ideas, as Allan Young has argued. [5] It also forged ‘A bridge … between “war neurosis” and the victims of civilian trauma that had never really existed before …. [In doing so it] helped to create a new, unitary kind of “trauma”.’ [6] Despite the almost reflexive use of ‘shell shock’ in moments of not-necessarily-traumatic shock, shell shock remains primarily a metaphor for the trauma and madness of warfare. By comparison, PTSD encompasses the psychological responses to a far greater variety of traumas. Amanda Holden may recently have expressed surprise at being diagnosed with PTSD following the traumatic birth of her daughter, claiming that she associated the condition primarily with the battlefield, but PTSD is regularly diagnosed in women who have had traumatic births, as well as victims of domestic violence and civil catastrophes such as railway accidents, taking it back to one of the earliest formulations of responses to psychological trauma, the 19th century condition ‘railway spine’.

Is PTSD becoming a cultural idea, then, through its use to define responses to traumas beyond the battlefield? I don’t think so. The framework within which it is used are still primarily medical, or medico-legal, and seek to limit the definition of those suffering from the condition, rather than expand it. No one has ever claimed of PTSD, as has been claimed of shell shock, that an entire generation suffered from it, and I doubt anyone will.

So no, PTSD is not simply ‘what we now call shell shock’, although it is possible to identify the condition initially termed as shell shock as an ancestor of what is now known as PTSD. But, as Hazel Croft argues, ‘Although each configuration of psychiatric injury draws on previous concepts, trauma has to be situated in the particular social, cultural and political circumstances … in which it is interpreted.’ [7] It is still possible to contextualised much of what is defined as PTSD this way; I am not sure the same can be said about the range of meanings that, today, the idea of shell shock is asked to encompass. It is not only that PTSD encompasses a potentially more sophisticated understanding of psychiatric disorder but that shell shock is not, and never really has been, a diagnostic term. It is far, far more than that.

Disclaimer: All of the above refers exclusively to my reading of the history of shell shock in Britain and the resonance of the term in British culture. The formulations of the meaning and significance of PTSD and shell shock as both terms and ideas in other cultures and other languages are different but are beyond my current competence and the scope of this post.